The Five Most Common Skin Allergies

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Is your neck itchy or your forearm bumpy just by chance, or are you suffering from a skin allergy?

Join us as leading experts reveal the five most common skin allergies and explain how to recognize and control them. From insect bites to metal and latex, you will learn what could be affecting your skin and how to recognize, prevent and treat allergy symptoms. Plus, we'll discuss common allergenic skin conditions like eczema and dermatitis and how best to treat them.

As always, our expert guests answer questions from the audience.

Announcer:
Welcome to this HealthTalk webcast. Before we begin, we remind you that the opinions expressed on this webcast are solely the views of our guests. They are not necessarily the views of HealthTalk, our sponsors or any outside organization. And, as always, please consult your own physician for the medical advice most appropriate for you.

Now here’s your host, Heather Stark.

Heather Stark:
It’s not uncommon to get a rash or a skin irritation at one time or another. Itchy, bumpy skin can be a warning sign of an allergic reaction. So how do you know when your rash is caused by an allergy or by something else? Hello and welcome to this HealthTalk webcast, The Five Most Common Skin Allergies. I’m your host, Heather Stark. During this webcast our expert guest will discuss common skin allergies and symptoms that go along with them. From eczema to hives, we will hear how skin allergies are diagnosed as well as how to prevent and treat them.

Joining us for our discussion is Dr. Roger Freidman, clinical professor of allergy, immunology and pediatrics at the Ohio State University College of Medicine and Nationwide Children’s Hospital. Welcome, Dr. Freidman.

Dr. Roger Freidman:
Thank You, Heather.

Heather:
Dr. Freidman, skin allergies are getting more and more common, especially where children are concerned. What exactly is a skin allergy, and how common are they?

Dr. Freidman:
Well, that’s a great question, Heather. Skin allergies and allergies in general have become much more common over the past 20 to 30 years, in fact. A skin allergy is when allergy will come out on the skin. In other words, allergies in general are when the body has an abnormal response to something that we come in contact with. If we come into contact with the substance in our nose, usually we will have a runny nose, or if it gets in our eyes, itchy, watery eyes. And many times when something comes into contact with our skin, it will show, it will manifest the reaction by coming out on our skin either as a hive, a welt or any other type of rash.

They have become much more common as you stated, and in fact right now somewhere about eight or nine percent of the population will show signs and symptoms of asthma, which is of course a lung allergy, and hay fever or allergic rhinitis, we have about 30 percent of the population, and skin allergies make up about 10 to 15 percent of the population will demonstrate and show skin allergies.

Heather:
You say it’s becoming more common. Why?

Dr. Freidman:
That’s the $50 million question right now. We have a number of theories as to why allergies are being more common. The main one that we have been working with is what we call the hygiene hypothesis. This is that when we are born, we are born with the potential to become allergic or not allergic, and you get that from your mom and dad, from your DNA. Throughout all history [a person] may be born with the potential to become allergic, but if you were exposed to lots of bad infections or noxious bad agents early in life – and that may be stuff like endotoxins, animal dander, sometimes that can be even be stuff like animal feces – if you are exposed to all these evil bad things early in life, your immune system has to defend itself. So it has to become an infection fighter, and when it becomes an infection fighter then it shifts away from becoming so allergic.

And now what we are seeing is that it’s a bit of an unintended consequence of our much better health and hygiene. Because of our vaccinations, because of our healthy lifestyles, because we live in cleaner environments, we now end up having more people develop allergies. So again it’s an unintended consequence of better health, and it’s certainly better, I believe, to have allergies than it is to end up having tuberculosis, malaria or measles.

Heather:
But it sounds to me like you are saying maybe we have gone a little overboard with being so clean that we are not developing those antibodies.

Dr. Freidman:
There is a hard line there, and it isn’t necessary that we are going overboard with clean. Actually a lot of it has to do with health, and by being healthier we are ending up with less severe things. But it is true that we are developing more allergies. One of the great things we are working on in the fields of allergy and immunology are ways of protecting ourselves from these infections and at the same time not becoming so allergic.

Heather:
Let’s talk about the most common types of skin allergies and their symptoms. What are those?

Dr. Freidman:
The most common that we will see, especially in pediatrics, especially in children, is what we call atopic dermatitis or atopic eczema. This is the typical rash that occurs usually in very early childhood. Babies will often develop these rashes on their cheeks, and later as they get a bit older they will be in the creases of their arms, in the folds of their arms, and on the back of their legs and on their knees. Certainly it’s very common, and we see it in somewhere again up to about 10 percent of the population will have this.

The atopic dermatitis is very often connected tremendously with allergies. In fact oftentimes we have what we call the atopic march. Those are babies who develop eczema early, and as they get a bit older, they develop asthma, and a little bit older they develop allergic rhinitis or hay fever type symptoms. And that’s the connection with what we call atopy, those three main diseases, and very often the atopic dermatitis may be triggered by either environmental allergies, but even more commonly by food allergies.

So really, the most common skin condition we have will be eczema. And again about 50 percent of them will be directly attributed to allergy and about 50 percent will be more just their skin problem. The second very common condition we will have is hives – the medical term is urticaria. Hives can occur from lots and lots of reasons, and maybe as we go on we will talk about those specifically.

The third type of skin allergies we will see is what we call allergic contact dermatitis. And all of us know about allergic contact dermatitis because either you have had it or you know someone who has had poison ivy or poison oak or poison sumac. Those are the most common, the plant dermatitises, when you get exposed to these plant chemicals. It’s a bit of a different reaction. It’s is not a true allergic reaction. It’s what we call a T-cell allergic reaction, so it’s a bit different immunologically. And you can also have contact dermatitises from a whole host of chemicals.

Heather:
What about jewelry?

Dr. Freidman:
Jewelry is certainly the next main thing, and that’s when you talk about nickel in particular. Nickel is the chemical that we talk about and is often in jewelry, especially in cheap jewelry and sometimes even moderately expensive jewelry. But lots of 18-carat gold, oftentimes there will be some nickel plating, and that will be very common. Of course as you are alluding to we will see it a lot of times in kids. It will be on their belt buckles, things like that where there will be a little bit of nickel plating, and that can definitely cause these allergic contact dermatitises.

I see a lot of patients in the work environment – again I am from Columbus, Ohio, and we have the Honda plant here up in Maryville, Ohio, and some of our patients who are working at an auto plant will come into contact with various chemicals that may cause a dermatitis to them.

One of the other common skin reactions will be drug allergies, and that will certainly be one that will very often show up on the skin. A patient taking an antibiotic or another type of agent or aspirin or ibuprofen can develop a skin allergy where they will break out into a rash that may be hives or may be eczematoid, and that’s another one of our common skin allergies. Then also what we will call the viral exanthems, and those are very often viruses that may cause skin type allergies, and a combination of a virus and sometimes even an antibiotic together can cause rashes.

Heather:
Are there any others?

Dr. Freidman:
That covers the majority of them. Some patients will have what we call pruritus, and pruritus just means itching, and often you will have this itching without a rash. Those can occur for a large number of reasons. Most of those are, when we find a cause, are medical in origin, such as someone may have problems with their kidneys or their liver. Those are some of the common reasons where someone will end up having itching without a rash, and it won’t be a true allergy.

Heather:
You talked about eczema, and I want to know how do you tell the difference between eczema and something like contact dermatitis, because don’t these kind of look alike?

Dr. Freidman:
They can, and certainly to the “non-doctor eye” they can. Even sometimes doctors, we can all be confused by them, but typically the eczema will occur in certain places in the body – babies on their faces, and as we get older in the creases of our arms and legs and back of the arms, places like that. Typically the contact dermatitises will occur, just as we say, in a place of contact. So, it’s pretty easy to see a linear distribution when we talk about poison ivy, say, where it’s covered in one small area and then goes down to another area. Usually a trained physician will be able to have a pretty good idea whether a skin rash is an atopic dermatitis or an eczema or whether it could be a contact dermatitis.

Heather:
Do they all look alike on the skin?

Dr. Freidman:
No. They may not all look alike on the skin. They can look very different at times. Some of them can be macular and papular, little papules, and certainly hives are usually more giant and filled. Of course if you have any of the blistering, that’s going to look much different. But sometimes they can have some similarities to them. Certainly contact dermatitis and viral rashes can look pretty similar for a while, and you sometimes need to sort through them and see what happens. One of the more interesting rashes we will sometimes have is a hot tub dermatitis, and those would be a bit of an allergic reaction or even a superficial infection the patients will get from being in, let’s say, a contaminated hot tub.

Heather:
Is that from like chlorine or is that like from bugs that are in the water?

Dr. Freidman:
It’s not from the chlorine. It’s actually from lack of chlorine. Sometimes it’s due to actually a bacteria, a pseudomonas that may be on the surface and may get just on the surface of the skin without causing anything severe but can be a difficult-to-sort-out rash for a while.

Heather:
That almost makes it sound like rashes are sometimes contagious. Are they? Are skin allergy rashes contagious at all?

Dr. Freidman:
Most of the skin allergies are not contagious. The eczemas and hives and drug reactions are not contagious. Sometimes you can certainly have an infection, and someone else can develop the same infection – think about things like measles or chickenpox, those are contagious diseases. You don’t get it from the rash typically. Although and most importantly, the one that gets people most confused is if you have an allergic contact dermatitis, again a poison ivy, those are not contagious.

Heather:
So you actually have to touch the poison ivy to get more poison ivy?

Dr. Freidman:
You actually have to touch the poison ivy. The reaction in the body is really what we call a T-cell immunologic reaction, and it’s the body’s response to the plant oil that causes the allergic reaction. The plant oil doesn’t stay on our skin for very long, so once you have either wiped it off, rubbed it off, showered, gone back anywhere, you are very unlikely to [transfer] contact to someone.

Heather:
When somebody has an allergic reaction, what exactly is going on in the body to cause those symptoms?

Dr. Freidman:
Again it depends what types of reaction we are discussing, but we will start with the two most common ones, and that’s the atopic dermatitis and hives. A lot of times the really main problem is that something you are allergic to, something that you have a sensitivity to comes into contact either with your skin or systemically with your body, and it causes the body cells called mast cells. Mast cells, if you can picture this, are like backpacks in our system. They are in our bodies. They travel up and down the blood stream, and the mast cells are filled with a chemical called histamine. That chemical, histamine, gets released into the skin, and when it does, if it goes on top of the skin it causes hives. If it gets in a smaller amount, then it oftentimes will cause the eczema, the atopic dermatitis.

So, both eczema and urticaria are really caused by the release of histamine, and that’s why so often when we treat people who get itching from their hives or itching from the eczema, we give them an antihistamine to counteract the effects of histamine.

Heather:
We usually think of those histamines as having something to do with like nasal drip or something.

Dr. Freidman:
Well, that’s right. Histamine clearly can cause a nasal drip in the nose. Again, when histamine gets released in the nose, it causes nasal drip. When the histamine and other chemicals – there is another slow-reacting substance of anaphylaxis – when it gets released into the lungs, that’s when it causes asthma.

But it’s really all about these mast cells, these little backpacks filled with these chemicals, and they are opening up and bursting out when they shouldn’t be. That is typically again for food allergies or hives, for eczema.

Now, when we talk about a contact dermatitis – again that’s what we call a T-cell system – and that’s where our bodies activate these other parts of our immune system, the T cells, the T lymphocytes. And the T lymphocytes migrate to the area where the oils are releasing a lot of their own chemicals causing a marked itchiness. Then usually, not only does it cause the itchiness, it’s the scratching a lot of times that will cause the rash.

Heather:
I remember my mother saying, “Don’t scratch it, you are going to make it worse.” But that’s easier said than done, isn’t it?

Dr. Freidman:
That’s easier said than done. Exactly right.

Heather:
What types of things cause skin allergies? You were mentioning food just now, so I suspect that’s one of them, but what are some of the other things that cause skin allergies?

Dr. Freidman:
Let me talk about food a little bit more because food is such an important one. Food is very important in causing two main problems. Number one is the eczema, as we have been talking about, and usually we will call it a mild food reaction, and that’s usually in young children. It’s typically caused by milk, egg, soy, wheat and fish. Those are probably the five biggest offenders for causing food allergies that causes eczema.

As children get a little bit older, that’s when we get into more problems with more severe food allergies, and that’s when we end up having hives, angioedema. What we call anaphylaxis or a severe reaction – and they usually start in the skin, and that’s what’s so important about them, we’ll start by seeing hives break out – they will progress onward to involve the entire system, and the entire system meaning the respiratory system, the GI system, and again even the cardiac or heart system where if you have massive release of these chemicals especially histamine, that’s where you can have fatal death events that occur.

Typically, most of the fatal events we have been seeing with food allergies occur from peanuts, tree nuts, and shellfish. About 80, 90 percent of deaths that occur and the most severe reactions that start as skin reactions are from peanuts, tree nuts and shellfish although any food potentially can cause a severe or life-threatening reaction. Again, this has been a huge health problem in Ohio and all over the country. All of my allergy colleagues in the country have just been seeing a real epidemic, an explosion of patients with severe nut allergies, and that’s been most concerning for school systems and for parents. When I started practice 25 years ago, one child in every school seemed to have a peanut allergy, and now it’s one child in every class that has a peanut allergy.

Heather:
That seems like a lot of increase.

Dr. Freidman:
Tremendous increase. And we are still trying to figure out why this seems to be happening. Again, it’s happening primarily in industrialized countries. We have been struggling with trying to come up with some answers to it, but it’s clear that it’s a dramatic increase.

Heather:
But it’s not just food that causes these skin allergies. We have got some other things too.

Dr. Freidman:
We certainly do. And as we talked about before, metals, such as nickel, can do it, and again almost any contact that we can see. There are so many chemicals that we are exposed to in simple things like our toothpaste. We have lots and lots of chemicals in toothpaste that sometimes can cause skin reactions. Lots of makeup and all of our bath and body type stuff, with the various fragrances and chemicals, can cause a skin reaction. So those are ones that are very definite, although again nickel is our most common.

Of course medications can cause skin reactions, as we have said. Either medicines you place on your skin or medicines that you ingest can cause a reaction, simple things – insects such as mosquitoes and of course bees. Bee stings can cause skin reactions and allergies that can either be mild, moderate or even severe.

Then sometimes there are seasonal allergies. When we talk about seasonal allergies, we are talking about things like grass pollen allergy, tree pollen allergy, molds, dust mites or ragweed. All those things – they tend to mainly cause runny nose, itchy eyes, coughing, congestion. But if you roll on the grass or stay on the grass long enough and if you are allergic to it, you are going to start breaking out in a rash, and you are going to start getting itchy skin from the environmental allergens.

I think those are probably our most important ones, and those will cover, I think, what most of our listeners will be interested in.

Heather:
We talked about what happens in the body, and we talked about some of the things that can trigger skin allergies. Who is at risk for developing a skin allergy?

Dr. Freidman:
For most of the people who develop skin allergies, there are two groups. One is of course the group who is allergic, who has inherited this allergic predisposition. They are the first ones to develop allergies. They are the ones who will see it much more commonly, and that’s the group of patients who we would [treat]. The second group is about 85, 90 percent of the population who can develop allergies to, say, poison ivy. Poison ivy is an incredibly skin-sensitizing allergen, and so it very, very commonly can cause problems with skin allergies overall. That’s something that we have to watch for, but that doesn’t require any definite predisposition, but the allergic one are those that do.

Heather:
Are children more likely to have skin allergies than adults?

Dr. Freidman:
Very much so. Eczema is much more common in children than adults, and in fact many of our children who have even very severe eczema, atopic dermatitis, as they get older they will tend to improve dramatically. So, most of our atopic people will get a lot better.

Heather:
You were talking about these mast cells with their little backpacks full of chemicals. Do people with skin allergies also tend to have another allergic disorder like maybe seasonal allergic rhinitis or asthma?

Dr. Freidman:
They absolutely do. That’s when I talked about this atopic march that most the children who have eczema will end up having food allergies. In fact about 50 percent of children with atopic dermatitis will have food allergies, and about 50 to 70 percent of children with atopic dermatitis will go on and develop either asthma or hay fever or allergic rhinitis symptoms. So they really are tied together, and it all has to do with what we call the IgE antibody. IgE is the allergic antibody, and that allergic antibody is what causes this.

Heather:
You mentioned that it is common for children to have skin allergies. Is it possible for children to outgrow those skin allergies? And how do they do that?

Dr. Freidman:
How they do that, we don’t know. It’s a bit confusing, but it clearly, truly happens. I guess the best answer is we know that the immune system is dynamic and changeable, and so where you develop IgE antibodies has a great deal to do with both what we call B cells and T cells, and sometimes they stop talking to each other, and that’s a good thing. If they stop talking to each other, we can’t become allergic, so we seem to outgrow it. In fact, that’s one of our strategies in trying to make people better from allergies – sometimes using allergy shots or immunotherapy, and that can change the immune system too.

Heather:
On the other side of that, some people develop allergies later in life when they never had them before. Why would that happen?

Dr. Freidman:
My simple theory is that since I am losing patients who outgrow it, I need some new ones to attend to as they get older. But in all seriousness, I think the answer is partly the same, that the immune system is dynamic, and it can go from being an IgE producer to a non-IgE producer, and sometimes something just switches the system back on, or switches it on for the first time, so that can definitely happen.

Heather:
So if it can change one way, it can change the other.

Dr. Freidman:
That’s exactly right.

Heather:
Dr. Freidman, how are skin allergies diagnosed?

Dr. Freidman:
Typically skin allergies like any of our allergies are diagnosed by seeing your physician and very often having an allergy test done. That can either be a skin test or a blood test. In that particular situation, we are measuring IgE or allergic antibodies to the offending allergens, and so you might skin test patients to foods, or you might skin test patients to pollens or molds or weeds or trees or even drugs sometimes. That’s one of the ways that we do it.

Then, if we are talking about contact dermatitis – that’s our nickel dermatitis or problems with chemicals – we do something called a patch test. In that you put a small amount of that allergen basically on a piece of paper, and we put it on a patient’s back, and we let it sit there for three days and see if it causes a reaction.

Heather:
It would be just as easy to wear the jewelry, wouldn’t it?

Dr. Freidman:
Or not to wear the jewelry. Or get some more expensive jewelry. But sometimes it is important, especially in a work environment. Sometimes people continue to have lots of problems from using common agents that they could tolerate before. Even simple things like Neosporin (neomycin, polymyxin, bacitracin ointment), which we use, you can become allergic to. You can become sensitized and allergic to things like Caladryl (pramoxine), which has Benadryl (diphenhydramine) in it, so those are all things that we have to be careful about.

Heather:
What type of doctor do you see for a diagnosis?

Dr. Freidman:
It would depend. Oftentimes you would start off seeing your family doctor, your pediatrician or your family physician, who may very easily be able to make a simple diagnosis, a presumptive diagnosis, and they may give you some simple medicines to try to treat you and see if those will work. If it’s more complex or you are having more problems, then you are either going to see the allergist or the dermatologist. Allergists deal with much more with the atopic dermatitis, with food allergies and hives and things like that. A dermatologist deals a lot with the contact dermatitises. They have an even bigger array of things they can test for in household chemicals and things we are exposed to. But both the dermatologists and allergists are the experts at dealing with skin-type allergies.

Heather:
Let’s say you suspect that your child has a skin allergy. What are those diagnostic tests that can confirm the parents’ suspicions?

Dr. Freidman:
To definitively confirm skin allergies, we will at that time usually do skin testing. Usually we will test children with a substance that we think they may be allergic to, either a simple scratch test or a prick test – which is the traditional allergy test – or sometimes we can do a blood test. A blood test can be especially helpful sometimes where there may be food involved. That’s the time when the blood test can be helpful. Then the last test, as I said before, is the patch test, which would be for a contact dermatitis.

Heather:
How do you determine the cause of that particular dermatitis? Does that patch test tell you that?

Dr. Freidman:
Well, yes. You would be taking your history, and you would have some ideas [what the allergy is] – again, if it’s a young baby, they usually have a limited amount of foods that they are eating. So if they are drinking milk and eating or drinking soy, or they are eating wheat and eggs, then there are a number of things that we would presumably test them for, if they are around cats or dogs. Now, there are some common allergens that almost everyone is exposed to, and that again depends in part on the area that you live in, but things like the various grasses, weeds, trees, molds or dust mites are common allergens that we will test for.

Heather:
Once you have identified that the patient is allergic to something, then you start treatment. How do you treat them?

Dr. Freidman:
That’s a great question, and that’s why we are in our field of our medicine. The most important thing that we do – and that’s why we think diagnosis is so, so important – the number one thing that we try to do is identify what you are allergic to and avoid it. And like you said, isn’t it easiest just to avoid wearing jewelry that has nickel in it? And the answer is absolutely. Also if you are allergic to a cat or a dog, is it best for the patient to not be exposed to that animal? Of course the answer is yes, although it may be much more difficult to convince the child or the family to get rid of a family pet, and we understand that. Those are two simple things.

Of course if someone is allergic to molds or dust mites, there may be some things we can do. If we find out they continue to be exposed to poison ivy, we may have someone go out there and spray the yard once and for all and get rid of the darned, pesky plant. That would be important to do. Of course if you are allergic to medications, obviously you are going to avoid those medications. If you are allergic to penicillin or you are allergic to anything like that, you want to try to avoid that, and that’s just so very important.

Now, if avoidance isn’t workable, that’s where we will start with medications, and typically our most common medicine that we are going to use is an antihistamine. The reason is that, no matter what type of skin allergy you have, most of them, at least the hives and the atopic dermatitis will have itching with it, so if we take an antihistamine, we can at least calm down the itching. Sometimes with children, their biggest problem is that they can’t sleep at night because they are rolling and scratching so much, and sometimes we will use an antihistamine that has a little sedation power and let them try to get a good night’s sleep. One of the things we will do with younger children too is, if they are scratching so much, sometimes we will actually put gloves on their hands for nighttime so that they won’t be able to scratch open sores and cause worse problems like more infection-type symptoms.

Lastly, of course, what we use most commonly to cool down the skin is we have a whole host of lotions, potions, and creams. They all have various degrees and various substances in them that can either calm the skin or work as anti-inflammatory to the skin or as an immunomodulator. We have really three big classes that we use skin cream-wise. We use moisturizers and lubricants. Those are very important especially with atopic dermatitis to keep the skin as moist as possible. You may have heard of such as Aquaphor, Eucerin or Lubriderm are common skin moisturizing creams that we will use a great deal.

The second type of creams are usually the corticosteroid creams, the cortisone creams – a whole host of names that everyone has seen. Hydrocortisone is some part of it, whether it’s a mild or moderate or very potent cortisone cream. Those are the various choices that a doctor will use to try treating, either a cortisone cream or cortisone ointment. Then we have these immunomodulatory creams, and these are called calcineurin inhibitors, and there are two trade names, Elidel (pimecrolimus) and Protopic (tacrolimus), both of which have been popular in the treatment of atopic dermatitis.

Then we have a couple of newer, noncortisone, nonimmunomodulator creams, one called MimyX and another Atopiclair. But again there is a whole host of creams that your doctor will be comfortable using in trying to make your skin rash go away.

Heather:
Are there any over-the-counter medications that can help relieve some of those symptoms?

Dr. Freidman:
Yeah, certainly. If they’re very mild symptoms, try using a 1 percent hydrocortisone cream, which is over-the-counter and very readily available. We use that a lot in mild symptoms and mild problems of eczema. The cortisone creams don’t do much for hives, and they don’t do too much for contact dermatitis, but they do a lot for eczema, and those can be helpful. And again the moisturizing creams are all over-the-counter. Those are again the Aquaphor, Lubriderm, Eucerin. Those are all over-the-counter and very, very good and can be very effective in trying to keep the skin moist, because one of the problems with atopic dermatitis, eczema, which is the most common form, is that the skin becomes very dry. When it gets drier, it gets itchier. So you want to seal in as much moisture as you can. So shortly after taking a bath or a shower before you are all dry, when you are kind of a little glistening wet, you want to put a moisturizing cream on there to keep that water in the skin.

Heather:
Do they ever use allergy shots to treat skin allergy?

Dr. Freidman:
That’s a very good question. In general, allergy shots are remarkably effective and very helpful for treating hay fever and for treating asthma. They do wonders. They make a dramatic difference overall. With eczema, typically we don’t use allergy shots, and the reason is most of the time eczema is much more likely caused by foods than environment. But there are occasional times where the environment is the main culprit in causing atopic dermatitis, the eczema, and that’s where sometimes you might consider it, but it’s really pretty rare that you would use allergy shots for eczema. One of the problems is that sometimes when you give allergy shots, it can actually make skin allergies a bit worse. So again, it’s not our usual treatment for skin allergies. It’s a much better treatment for nasal and pulmonary, lung allergies.

Heather:
We talked about avoidance as a way to treat allergies, but if somebody is allergic to outdoor allergens, how can they possibly avoid that?

Dr. Freidman:
It’s very difficult. First of all, the one thing you can do is, when you are inside, keep your windows closed, have your air conditioning on and give yourself a safe environment when you are not outside. Try to limit the amount of time you are outside, try not to go out in the early day when the allergens are at their highest. When you have been outside, come in and shower afterwards. It’s pretty tough to lead a nice, healthy, normal life, be allergic and avoid outdoor stuff. If you are allergic to the outdoor environment, the trees and the grasses and ragweed, usually you are going to need to be on some sort of therapy, either medications, allergy pills or nose sprays, or the possibility of being on allergy shots, again if it’s more nasal or pulmonary problems.

Heather:
Is there any kind of cream that would help protect – like sunscreen or something – that you put on before you are exposed to help?

Dr. Freidman:
In general, barrier creams for the environmental things aren’t very effective overall, so they probably don’t do too much. There are some creams that are reported to have some mild benefit with poison ivy to use, ivy cream, but they really have very little, great scientific benefit.

Heather:
So you can’t live in a bubble, huh?

Dr. Freidman:
You can’t live in a bubble, and you don’t want to. That’s the most important thing.

Heather:
We have a lot of e-mail questions, so I want to get right to them. The first one is from Suffern, New York, “My daughter has little bumps on her upper chest, back and upper arms. She is 12 and embarrassed. Could this be from an allergy? And what can we do about it?”

Dr. Freidman:
As you know, it’s a little hard to see the rash through the phone, so it makes it a little more challenging, but most likely what she probably has is what we call keratosis pilaris. Keratosis pilaris (KP) is a rash that typically occurs on the arms and sometimes on the cheeks. It looks again a little bit like eczema, but it’s a little bit rougher than that, and it is a little bit disconcerting for young ladies especially but also for some boys too. The good news about keratosis pilaris is that most of time this is something that will go away as she goes through puberty. We can moisturize with creams and make it a little bit better – one of the hallmarks is it’s is not itchy, doesn’t bother them – but it doesn’t change much. It’s a very common rash, and it’s not an allergy, although it can be associated with people who have allergies. But hopefully a little patience and a little time and sometimes a little moisturizing cream can help a bit, but it almost always will get better.

Heather:
Is it associated with eczema?

Dr. Freidman:
It’s not associated with eczema, but it’s sometimes associated with people who have other allergic problems.

Heather:
I asked because I think my son had that when he was little, and he also had eczema.

We have an e-mail from Kentucky, “I usually can wear silver jewelry, but lately when I wear my silver necklace, I get a dry, itchy rash on my neck. Is it possible to suddenly become allergic to something I have never had a problem with in the past?”

Dr. Freidman:
That’s a great question, and the answer is yes. It is possible to suddenly become allergic to something you haven’t been. Sometimes, though, it may be that particular piece of jewelry may have leached out a bit more nickel in it and so may now be causing a problem. But yes, and unfortunately, once you become sensitized to a piece of jewelry, it’s usually going to stay that way. So the odds are that she is going to have to find a new chain or a new piece of jewelry.

Heather:
I have this and sometimes when it starts bothering me, I just clean it really well.

Dr. Freidman:
Sometimes cleaning can help a little bit, and sometimes a little bit of cortisone can get you through it, but usually once it starts happening, it’s going to be a problem.

Heather:
We have an e-mail from Portland, Oregon, “Why does my skin get flushed and itchy when I drink even just the littlest amount of red wine?”

Dr. Freidman:
That’s another interesting one. Typically, red wines will have a lot of what we call metabisulfites in them. Metabisulfites are preservatives placed in all wines, but they are usually in higher quantities in red wines, especially American red wines, domestic wines. So, oftentimes when you drink some wine, it will cause flushing because of the bisulfites. Typically, you can play around with that a bit and find some other wines, usually from Italy and France, that you might be able to tolerate, and that certainly can happen. Some people will have reactions from the nitrosamines in the red wines, but most of the time it’s due to the metabisulfites. It’s usually not dangerous or deadly, but it can be annoying.

Heather:
So short of doing home brew, she can check out those European wines?

Dr. Freidman:
Yes. The European wines usually have a lot less of the bisulfites in them. [Also, she could look for preservative-free organic wine.]

Heather:
We have an e-mail from Reno, Nevada, “When I get really cold, I get these reddish bumps on my ski – cheeks mostly but also on my legs. Could that be a skin allergy, and if so, what am I allergic to?”

Dr. Freidman:
I must admit, Heather, these have been some amazing questions because they have brought up probably some of the few areas we haven’t talked about.

Heather:
Good.

Dr. Freidman:
Yeah, it is good. That’s a condition that we call cold-induced urticaria. When we talked about hives before, hives can be caused by lots of things. Hives can be caused by allergens. Hives can be caused by infection. Hives can be caused by autoimmune problems and often by physical things such as heat, cold, sweat and exercise. Cold-induced urticaria is very common, and I don’t know if that one was the one from Portland, but up in Portland if they go on the coast, then that freezing cold water will do it to a lot of people.

Heather:
Actually, that one was from Reno.

Dr. Freidman:
That one was from Reno. Well, then Reno can do that too. But typically it will be when you have gone from warm to cold. A lot of times going into a pool or in the Midwest here when we go out into the snow, you can get some hives. Typically, simple antihistamines can be very effective to treat it. It’s is not very dangerous. It’s just a bit annoying at times. You have to be a little bit careful because there are occasionally some diseases that can be associated with this, but that’s very unusual. Mostly it’s very mild, and the only danger point is that sometimes you have to be a little bit careful that if you were to go swimming by yourself in a very cold area that sometimes you can release enough histamines that you could pass out, and passing out under water is a bad thing to do. So I tell people with cold-induced urticaria they need to swim with a friend.

Heather:
Very interesting. And so probably she should discuss that with her family doctor too?

Dr. Freidman:
Yeah. That sort of thing should be discussed with your family doctor, because a lot of medicines, a lot of antihistamines can be given to treat that in particular.

Heather:
That’s really interesting because of course I have heard, living in Ohio when I was growing up as we were talking about, you get that heat and that humidity, and so you are sort of used to the idea of getting the hives in the summer from the heat, but I didn’t know you could get it from the cold.

Dr. Freidman:
Yeah, you can definitely get it from the cold, and usually it’s from change in temperature. You have been pretty warm and then you go into a cold shower or a cold bath or into the pool.

Heather:
Let’s go to an e-mail from Fort Worth, Texas, “My son has terrible eczema. The creams his doctor gave us don’t seem to help. How is eczema usually treated, and are there any home remedies we should try?”

Dr. Freidman:
The answer is certainly. Usually if it’s really severe, you are going to want to do it with a specialist helping you, but the home-type remedies that we can use are of course making sure that we bathe or shower appropriately, meaning in lukewarm water, and as soon as we get out to moisturize the skin. Again, try to see if you can identify things that might be precipitating the problem, and work at decreasing the itching and the scratching as much as you can. The home remedy of wearing gloves at night, that may be helpful for a younger child to try to not scratch. Keeping their nails cut very clean.

There are no effective vitamins, nutritional supplements, any of that that’s been particularly effective with eczema. It’s a very frustrating condition. Those of us that do this for a living, we see lots of really sad stories of again children who go through this really tough time with bad atopic dermatitis, and it can be difficult for the family and. But the good news is that eventually most of our kids with eczema will get a lot better.

Heather:
You have mentioned the moisturizing after a shower. Does it make a difference if you moisturize while your skin is still damp or if you just wait until you are all dry?

Dr. Freidman:
You can spread the cream much farther on a little bit damp skin. It saves you a lot of money, plus you are trying to get that water into the skin. If you take it all off by drying it, now you are just adding cream. So you really want to try to trap the water a little bit better that way. We always use the glistening damp. You get just a little bit of dampness to you.

Heather:
We have an e-mail from Charlie from Topeka, Kansas, “What can I do if my patch test comes back positive, and I try to avoid the substance – which in my case is perfume – that causes an allergic reaction to my skin, and the thing that’s most used to relieve the reaction is cortizoid cream, and my skin is allergic to that?”

Dr. Freidman:
Charlie has got a problem. Again there are some of these immunomodulator creams – two trade names of prescription medicines, Elidel, Protopic, they may be effective if he is truly allergic to the cortisone creams. Sometimes some of the pharmacies can manufacture for him some cortisone cream that may not have the chemical that he’s sensitive to, but it is a challenge. There is no question. And if worse came to worse, if someone was having a horrible problem, we can always give oral cortisone or prednisone pills, and that can make almost all these skin rashes better. The problem with cortisone is that it has a lot of side effects, so you try not to do that.

Heather:
But that’s interesting when you say that they can manufacture or customize a cream that would have the main ingredient, the cortizoid, but not some of the other additives that they might find in the over-the-counter medicines?

Dr. Freidman:
That’s right. You need to find a compounding pharmacy to do that.

Heather:
And the pharmacy, you don’t go to the doctor, you go to the pharmacy?

Dr. Freidman:
You would need a prescription from the doctor, and then you go to the pharmacy.

Heather:
We have a question from Sacramento, California, “The inside of my thighs gets irritated when rubbed lightly. As a small child I had this problem in that same area, but when I hit my teens, the problem went away. It’s back now, but the skin is not discolored and doesn’t itch. This seems to come and go. The area is never irritated in the morning but usually gets worse during the day. My dermatologist said she doesn’t see anything. I am physically fit and don’t take any medications. Could this be a type of skin allergy?”

Dr. Freidman:
It probable isn’t. It’s probably more of a sensitivity to the skin, something we call dermagraphism, where the skin just releases those histamines for no good reason on occasion. So it’s effectively similar to a skin allergy, but it ends up not being a skin allergy. Again, sometimes antihistamines can be helpful for that. Sometimes a combination of different antihistamines may be helpful to make a difference, but that’s a challenging, difficult one, and you are going to be most likely continuing to work with your dermatologist to come up with the best solution for that problem.

Heather:
Let’s go to Nashville, Tennessee, “I have recently been diagnosed with seborrheic dermatitis and dealt with very red and flaky dry skin on my face. My internal medicine physician just prescribed me with Nizoral (ketoconazole) cream, which has helped, along with a combination of yogurt. Is it true that seborrheic dermatitis is linked to yeast and that eating yogurt helps calm the reactions down?

Dr. Freidman:
Most people do not believe that seborrheic dermatitis is connected to yeast. I think most traditional medicine doesn’t believe that there is much of a connection per se. But it’s clear that Nizoral shampoo can be effective, and it’s a bit of an anti-fungal agent. We think what sometimes happens with the seborrhea is that there is a superficial infection of fungus. Again, most traditional dermatologists don’t feel that the yogurt has too big a role, but if it’s working, there is certainly no negative. It’s a safe and easy food to use, and there certainly are things we don’t always know right now to be true.

Heather:
We have an e-mail from Raleigh, North Carolina, “I broke out in severe hives from penicillin as an adult. I am worried that the allergy could become more severe and cause a worse problem than hives, like anaphylactic shock. Is it possible to become severely allergic if your first reaction was just hives?”

Dr. Freidman:
Absolutely. That’s a very good question. Very often the first reaction you have to a food or to an antibiotic may be mild, and if you keep becoming exposed to it, keep re-exposing it, then it can be more severe later on. That’s true of foods in particular too, along with drugs, and that’s why once someone has had a penicillin reaction like you have just described, you will strictly avoid penicillin for the rest of our lives. I’m not sure it will have to be that long, but it may very well be. That’s definitely important to do.

Heather:
E-mail from Baltimore, Maryland, “How can I attribute my allergic reaction to makeup when I have used the same cosmetics for years?

Dr. Freidman:
That’s what often happens, and there are a couple of answers to that. The first is, sometimes the same makeup can change – sometimes they manufacture it a little bit different. They have a little bit different stuff in it. They don’t have to always tell you that, and sometimes you will find that. That’s certainly a possibility.

The other possibility that happens is that the constant application of a cream over time can sometimes sensitize you to it. A little bit of it never caused a problem, but when you do it day in, day out, for weeks, months or even years, then your T cells sometimes can get turned on to that problem and do it. So that’s how that happens.

Heather:
So should she look to see if they have changed the composition?

Dr. Freidman:
Look to see if they have changed the composition. Again, sometimes you may even find trying another batch of the same may be different or an older batch sometimes, but it’s a challenge. You have to be a little bit of a detective to try to sort some of that out. Your dermatologist especially can be the person who can work through that with you.

Heather:
You just said something that piqued my interest. You said sometimes it’s older. Can makeup and creams change if they have been on your shelf a long time?

Dr. Freidman:
Absolutely, they can. Yes, they sure can. But sometimes an older makeup may be better tolerated than the new one. The new one may have changed.

Heather:
We have an e-mail from Phoenix, Arizona, “I have heard castor oil is helpful for skin allergy. Is that true?” What is castor oil?

Dr. Freidman:
It’s made from the castor bean. Any oil – you can use Crisco – you can use anything that’s moisturizing and that you can put on your skin. Some people, again I mentioned Crisco because it’s cheap, and so if economics are a major issue, someone says what else can I get? I have got to try something. You can try that. Vaseline is another one that’s not too expensive in some of the off-brands. But in general I don’t think there is any major benefit from castor oil as opposed to some of the other oils.

Heather:
What about udder ointment? Bag balm, I guess they call it.

Dr. Freidman:
Yeah. Any of those things can be helpful. Anything that can lock in moisture can be helpful.

Heather:
Question from Las Vegas, “Is it possible to be allergic to water?” I had a 10-year-old who tried to convince me of that one. “Sometimes when I get into the bath, and it is just water, I break out in hives.”

Dr. Freidman:
Yeah. We do have, as I mentioned, the physical urticarias can be due to water, cold. Usually when it’s water, it’s due to the change in temperature. It’s usually that the water is cooler than anything else that you have been in. So if you get in a hot bath, I don’t think that would happen. But there are some people who can be sensitive to sun. They can be sensitive to pressure, areas around your belt or your pant line or things like that can be pressure urticaria. Certainly some people, rarely, could truly be [allergic to] water, but most water problems have to do really with cold.

Heather:
Could it be something in the water? Sometimes when I turn on my shower or whatever, I smell chlorine or I smell some sort of chemical, and sometimes it’s worse than others. Could there be additives?

Dr. Freidman:
Yeah. There is no question that sometimes there can be substances in the water that can do that. Yes.

Heather:
We have an e-mail from Boise, Idaho, “What options are around for someone trying to find the right antibiotic and topical treatment for a skin allergy when the options are limited? I am allergic to minocycline, and so the doctor has been trying all sorts of antibiotics and creams. Currently MetroGel (metronidazole) doesn’t seem to be working. Are there any naturopathic suggestions that work when antibiotic creams or gels are not an option?

Dr. Freidman:
To be totally honest, I am not certain that I know of any that have been shown to be safe and effective. But most of your good dermatologists have a good working use of all those sorts of creams and may come up with something alternative-wise if need be, and I just don’t know of anything.

Heather:
We get a lot of people who want to know about natural and alternative [treatments]. Any advice for people who are looking for natural or alternative?

Dr. Freidman:
The nice thing about natural for skin is that if you are just putting something on your skin, there is very little to any danger of it. I think that’s important. We’re always a little bit worried about natural when it may not be natural, but if you are going to put it on your skin, you can see if it causes a reaction. It’s easy, and it’s safe. The health food stores certainly have some ideas about certain things, the creams, and I don’t have any worries for the most part about using natural creams on patients and see if they get some benefit.

One of the things you asked earlier, primrose oil, has been used a lot of times, and I will call that a natural ointment that people have used and even primrose oil tablets for eczema. There has been some slight benefit, but the newer immunomodulatory agents are just much more effective.

Heather:
I used to raise sheep, and when I was working with the wool, the lanolin in the wool made my hands very soft, and I didn’t have any rashes or anything. Is lanolin good for eczema?

Dr. Freidman:
Lanolin is very good. Lanolin is in so many other things. Now interestingly lanolin can be a sensitizer – some people become allergic to lanolin, and so that’s always something you always have to be aware of too.

Heather:
Let’s go to an e-mail from Santa Fe, New Mexico, “I was told that if I didn’t breastfeed my baby, she will develop allergies. What is the relationship between breastfeeding and allergies?”

Dr. Freidman:
Let’s get to the good part about breastfeeding – breastfeeding has a lot of good things to it. It has got a lot of very good things to it in that it helps the baby’s nutrition. It helps baby’s immune system, and it probably slightly decreases the chance of allergies. So if possible, it’s best for a mom, if she can, to breastfeed for four to six months, again if breastfeeding works and if mom and baby are coordinated well together, either because of mom working or other reasons. So breastfeeding is a good thing to do. But you don’t need to feel guilty if you didn’t breastfeed because it’s a very small percentage change in protecting from developing allergies, and many, many, many babies who are breastfed will still develop allergies, and many babies who aren’t breastfed won’t develop allergies.

Again, we always say, “breast is best.” When I was a young pediatrician, I was taught by one of our mentors, the best thing about breastfeeding is that it’s the right stuff, it’s at the right temperature, it’s the right amount of calories, and it comes in a cheap package. That’s what our pediatricians used to say about breastfeeding.

Heather:
Well, I am here to tell you, my first child I breastfed for 14 months, and that kid is allergic to everything.

Dr. Freidman:
That’s right. We have done some very recent studies, and it is a bit protective, but it’s a percentage issue. So if there was a 50 percent chance to become allergic, and now there is only a 40 percent, that’s nice, but it still means that 80 percent of the people would still become allergic.

Heather:
Let’s go to an e-mail from Pennsylvania, “How can I keep my son from scratching his eczema, and will his scratching cause scarring?”

Dr. Freidman:
His scratching won’t cause scarring. That part is good. In general scratching doesn’t cause scarring, so that’s nice. The best ways, as we have been talking, are if you can identify things that trigger the problem, avoid them, whether it be foods or the environment. Number two, oftentimes give an antihistamine to make him less itchy. Number three, using the various creams, either moisturizing or the cortisone creams, can be helpful. And lastly, again if it’s happening a lot at night, sometimes literally putting his hands in cotton gloves that are safe and not letting him get at the skin.

Heather:
We are almost out of time, but before we go, Dr. Freidman, do you have any final thoughts for our listeners?

Dr. Freidman:
I think that from the questions and from our discussion, everyone can see that allergies have become an even bigger problem in this 21st century. Skin allergies are fortunately very rarely life-threatening, but they definitely can affect the quality of life. And so something that we want to work very hard to do is to try to identify things when we have the problem and ways of avoiding the exposure and using good medications. Again, seeing your primary care doctor when needed and your specialist if we need even more expertise.

Heather:
Sounds like good advice. And I had a real quick question I wanted to throw in here. If you are itching and you don’t want to scratch it, does an ice bag help?

Dr. Freidman:
Absolutely. And I’ll tell you where it helps the most: It helps for itchy eyes. Use an ice bag on itchy eyes, and we have gone through a horrible pollen season here in Columbus and at the Nationwide Children’s Hospital this year. We have had one of our worst seasons ever of bad allergies, and so using ice bags on the eyes has been effective.

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